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Borderline Personality Disorder in Residential Care Facilities
When I received my August 2012 issue of Annals of Long-Term Care, I was very pleased to read that hearing loss without regular access to hearing aids might be a trigger for nursing home (NH) residents with dementia to exhibit troubling behaviors. I also liked the fact that in another article, the disability movement, of which I’m a member, deserves credit for some progressive ideas adopted by the NH reform movement.
The reason I’m really writing to you is to express my distress at the description of the NH resident described in “Case 1” of the article “Borderline Personality Disorder in Residential Care Facilities” (www.annalsoflongtermcare.com/
article/borderline-personality-disorder-residential-care-facilities). The behaviors of the woman discussed included being somewhat depressed, difficult, uncooperative, intermittantly noncompliant, splitting, hostile, complaining about trivial (my emphasis) hospital logistics, thoughts of self-harm but no actions, and feeling abandoned by her children.
I’d like to point out that these same behaviors have been described by psychologists in the long-term care literature as “nursing-home–induced post-traumatic stress disorder.” I personally think that all of the “behaviors” expressed by the case 1 resident can be seen from a resident’s point of view. Quite a few NH residents have mild depression due to living in a NH. As far as being uncooperative, I would have liked to see some examples. The fact is that NH staff are interested in control, and, in some cases, residents are uncooperative in an attempt to empower themselves in an enviroment where they have little control, which is an effort I applaud. As far as noncompliance is concerned, all NH residents have the legal right to refuse treatment, whether staff like it or not. “Splitting” is a fancy term for blaming an observant resident who can distinguish between high-quality and inferior care providers. The fact that the resident is described as being quiet and compliant on some shifts probably means she had better caretakers on those shifts.
“Hostile” is how residents often feel when they are mistreated by or not listened to by staff. As for food, even a dying rommmate of mine who would only eat certain foods was described as “stubborn” by a staff member. So, family, other staff, and I made sure she had the foods she wanted.
This brings me to thoughts of self-harm. Although such thoughts are perceived negatively, when they occur without action, they can actually be adaptative: a way for a resident to calm himself or herself by believing there might be a way to escape the surreal place in which he or she is forced to live. As far as the case patient feeling neglected by her children, one of our best certified nursing assistants sometimes complains that her adult children do not financially support her so that she can quit her job. Does this mean that a NH resident does not have the same right as an employee to feel hurt by her children? It turns out that a treatment for this borderline personality disorder is to create a “validating environment.” That’s exactly what NH residents need: someone who actually realizes that their concerns are reasonable. In my facility, luckily there are many staff who do, including our fabulous director of nursing.
I would like to share that our many wonderful international staff are on top of this problematic and very serious aspect of American culture…labeling individuals as having psychiatric disorders unnecessarily. They roll their eyes and have their mouths agape at the psychiatricization they did not see in their countries of origin.
In conclusion, I’d like to say that many of the identified problems are systemic to NHs across the United States—the result of inadequate staffing and training as well as industry profits that consume money needed for direct care. Personally, I live in an excellent facility where staff are professional, caring, and resident-directed. I wish every nursing home resident could live in as good of a nursing home as I do, and I am working toward that goal. That doesn’t mean that together we can’t work on some improvements. Dr. Alice Bonner, director, Nursing Home Division, Survey and Certification Group, CMS, has me involved in CMS’ Quality Assurance and Performance Improvement initiative. CMS’ goal is to to involve all the stakeholders, including residents, in quality improvement in facilities. I hope the staff at my nursing home will be courageous in permitting me to participate in this initiative openly. I trust they will. They’re remarkable!
Penelope Ann Shaw, PhD
Board Member
Massachusetts Advocates for
Nursing Home Reform
Leadership Council Member
National Consumer Voice for
Quality Long-Term Care
Advocate and Policy Advisor,
Nursing Home Division
Survey and Certification Group CMS
Board Member Disability
Policy Consortium (Boston)
The authors respond: We thank Dr. Shaw for her letter regarding our article “Borderline Personality Disorder in Residential Care Facilities” (2012;20[8]:34-38). Dr. Shaw states that residents in assisted living facili- ties and physicians have a different understanding about managing particular behaviors pertaining to pervasive and long-standing personality disorders. Regarding case 1 of our article, Dr. Shaw states, “The behaviors of the woman discussed included being somewhat depressed, difficult, uncooperative, intermittantly noncompliant, splitting, hostile, complaining about trivial (my emphasis) hospital logistics, thoughts of self-harm but no actions, and feeling abandoned by her children.” A diagnosis of borderline personality disorder (BPD) is reflected by a prolonged dysfunction of personality, characterized by affective instability that may secondarily affect cognition and interpersonal relations, as well as issues with self-image, identity, and behavior, including self-harm, that are present over time and in many social contexts.1
Understandably, residents initially admitted to a long-term care (LTC) facility may display symptoms of anxiety regarding their new surroundings and difficult transitions. Moreover, chronic illnesses associated with the process of aging and, ultimately, of dying are anxiety-provoking and may become an integral part of life for LTC residents.2 As Dr. Shaw points out, a significant proportion of LTC residents experience mild depression that often remains unidentified by the staff, yet treatment may help them to cope effectively with those feelings.3 However, a longitudinal history in both of the cases we presented in our report confirmed the presence of similar behaviors since early adult life in many social contexts, well before these patients arrived at nursing homes. Changes in their environments triggered a “caricature” of maladaptive behaviors, along with affective dysregulation, justifying the diagnosis of BPD.
Epidemiological community studies show that the prevalence of personality disorders in individuals aged 65 and older is up to 15%.4 However, there is a paucity of studies assessing the prevalence rate of personality disorders in LTC settings, likely due to a variety of factors. The longitudinal history to distinguish acute symptoms from chronic behavioral patterns may be unavailable or unreliable. Previous medical records, including LTC records, often lack extensive past psychiatric and psychosocial history, which are required to make such a diagnosis. Disruptive behaviors in older adults are often considered normal and, in addition to lacking a longitudinal history of premorbid personality disorders, physicians often defer a diagnosis of a personality disorder.5
Due to the pervasive nature of personality disorders, the treatment strategy is to decrease the frequency and intensity of disruptive behaviors. This optimally involves multidisciplinary teams working together to decrease medical and environmental stressors that may exacerbate per- sonality dynamics and maladaptive behaviors. Therefore, LTC staff may understand these deficits occurring in the context of a personality dysfunction, and when they understand them in this manner, they may become less over-responsive and more predisposed to providing empathic responses to the disruptive behaviors.
In summary, our article highlights that treating BPD patients in LTC settings requires use of multiple strategies, including psychotherapy and pharmacotherapies. Psychotherapy in LTC settings can be problematic due to psychotherapists’ availability, patients’ cognitive impairment, and the presence of comorbid medical conditions that may interfere with patients’ ability to participate. It is known that the use of dialectical behavior therapy (DBT) is the most practical intervention, as it has been shown to decrease the incidence of self-harm behavior, depression, anxiety, hopelessness, number of hospitalizations, and length of hospital stay.6,7 Physicians need to be thorough and cautious about the diagnosis of personality disorder. When rendering such a diagnosis in an older adult, there needs to be a long-standing pattern of behavior consistent with personality disorder, antedating any recent disruption in the patient’s social environment, such as difficulty in adjusting to institutionalization or some other external social variables. Older patients with personality disorders may well benefit from similar psychotherapy models offered for the same personality disorders in younger patients.
Ana Hategan, MD
McMaster University, Canada
James A. Bourgeois, OD, MD
University of California San Francisco
Elise Hall, MD
McMaster University, Canada
References
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Grant BF, Hasin DS, Stinson FS, et al. Prevalence, correlates, and disability of personality disorders in the United States: results from the national epide- miologic survey on alcohol and related conditions. J Clin Psychiatry. 2004;65(7):948-958.
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Robins CJ. Dialectical behavior therapy for bor- derline personality disorder. Psychiatr Ann. 2002; 32:608-616.
